经皮穿刺气管切开术应用于急危重症患者的疗效

目的:观察经皮穿刺气管切开术应用于急危重症患者的疗效。方法:将2004年5月—2008年7月收治的112例需行气管切开术的急危重症患者分成2组,56例行经皮穿刺气管切开术治疗(研究组),56例行开放性气管切开术(对照组)。比较2组患者的手术时间、切口大小、术中出血量、拔管后切口愈合时间与并发症。结果:研究组手术时间(9.11±0.83)min,切口直径(1.06±0.25)cm,术中出血量(7.54±1.65)mL,拔管后切口愈合时间(4.27±0.44)d,并发症发生率14.28%(8/56);对照组手术时间(21.62±0.79)min,切口直径(3.25±0.31)cm,术中出血量(22.5±1.83)mL,拔管后切口愈合时间(7.62±0.65)d,并发症发生率21.43%(12/56);2组比较差异均有统计学意义(P0.01)。结论:经皮穿刺气管切开术具有简便、切口小、出血少、愈合快、并发症少等优点,适用于急危重症患者的抢救治疗。     

A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy

A prospective non-randomized study was undertaken to compare, in intensive care patients, the safety and utility of a percutaneous tracheostomy technique performed at the bedside with a surgical tracheostomy technique performed in the operating room. During a 21 month period, 153 percutaneous tracheostomies were performed. Complications occurred in 6 patients (3.9%). Secondary wound haemorrhage occurred in 4 patients and primary wound haemorrhage occurred in 2 patients. During the same period, 74 surgical tracheostomies were performed. Complications occurred in 14 patients (18.9%) which included tracheal obstruction, haemorrhage, pneumothorax, wound infection, wound breakdown and one death. In comparison to surgical tracheostomies, percutaneous tracheostomies were rapidly and easily performed at the bedside and were associated with significantly fewer complications.     

气管穿刺导入气管套管术在急救患者中的应用

目的 :观察改进的气管穿刺导入气管套管术在危重患者紧急抢救中的应用疗效。方法 :对 132例急诊科及 SICU患者用 PORTEX L IMITED全套器械行气管穿刺术 ,从外套管内送入导引钢丝 ,沿钢丝导入专用气管插管到气管内 ,再拔出气管插管内栓及导丝。结果 :气管套管术操作需时 2～ 2 0分钟者共 12 3例 ,>2 0分钟者 9例 ,较常规气管切开所需时间缩短 ,且可单人操作 ,一般可在 3～ 10分钟完成 ,顺利者在 4～ 7分钟完成。术中损伤小 ,出血量少 ,伤口愈合时间短 (1～ 2日 )。结论 :气管穿刺导入气管套管术操作方法简便 ,组织损伤轻微 ,出血量少 ,可以单人施术 ,适于急救中应用。     

利多卡因在气管切开患者吸痰中的应用

目的 减轻气道吸引时给患者带来的痛苦及不良反应.方法 将63例气管切开意识清醒患者随机分为观察组32例和对照组31例.对照组用常规方法进行气道内吸引,观察组吸引前用2%利多卡因0.5～1 ml沿气管内壁缓慢注入,待2～3 min后再行气道内吸引.结果 观察组与对照组在发生刺激性咳嗽、躁动等方面存在统计学显著差异(P＜0.01);在吸痰时与吸痰后2 min,血氧饱和度读数均值两组存在统计学显著差异(P＜0.01);吸痰后5 min血氧饱和度读数均值两组存在统计学差异(P＜0.05).结论 在气道内吸引前用2%利多卡因气道内注入,明显减轻机体的反应,降低对气管的刺激性,减轻了患者的痛苦.     

经皮气管切开术在ICU危重患者中的应用

目的探讨经皮气管切开术（PT）在ICU危重患者中的应用价值。方法前瞻性随机将168例需气管切开的ICU危重患者分为两组：经皮气管切开术组和传统的气管切开术（OT）组，并对两组手术时间、切口大小、术中出血量及各种并发症的发生率和手术死亡率进行比较。结果PT组的手术时间与手术切口长度都明显短于OT组（P〈0．01），出血量明显少于OT组（P〈0．01），两组的并发症发生率比较有显著性差异（P〈0．05），而两组的手术死亡率比较则无显著性差异（P〉0．05）。结论经皮气管切开术是一种微创快捷的急救技术，尤其适用于ICU的危重患者，在ICU人工气道建立中有很大的应用价值。     

Tracheostomy timing and the duration of weaning in patients with acute respiratory failure

Introduction

The effect of various airway management strategies, such as the timing of tracheostomy, on liberation from mechanical ventilation (MV) is uncertain. We tested the hypothesis that tracheostomy, when performed prior to active weaning, does not influence the duration of weaning or of MV in comparison with a more selective use of tracheostomy.

Patients and methods

In this observational prospective cohort study, surgical patients requiring ≥ 72 hours of MV were followed prospectively. Patients undergoing tracheostomy prior to any active weaning attempts (early tracheostomy [ET]) were compared with patients in whom initial weaning attempts were made with the endotracheal tube in place (selective tracheostomy [ST]).

Results

We compared the duration of weaning, the total duration of MV and the frequency of fatigue and pneumonia. Seventy-four patients met inclusion criteria. Twenty-one patients in the ET group were compared with 53 patients in the ST group (47% of whom ultimately underwent tracheostomy). The median duration of weaning was shorter (3 days versus 6 days, P = 0.05) in patients in the ET group than in the ST group, but the duration of MV was not (median [interquartile range], 11 days [9–26 days] in the ET group versus 13 days [8–21 days] in the ST group). The frequencies of fatigue and pneumonia were lower in the ET group patients.

Discussion

Determining the ideal timing of tracheostomy in critically ill patients has been difficult and often subjective. To standardize this process, it is important to identify objective criteria to identify patients most likely to benefit from the procedure. Our data suggest that in surgical patients with resolving respiratory failure, a patient who meets typical criteria for a trial of spontaneous breathing but is not successfully extubated within 24 hours may benefit from a tracheostomy. Our data provide a framework for the conduct of a clinical trial in which tracheostomy timing can be assessed for its impact on the duration of weaning.

Conclusion

Tracheostomy prior to active weaning may hasten liberation from ventilation and reduce complications. However, this does not reduce the overall duration of MV.

     

经皮旋转扩张气管切开术在神经科危重症患者中的应用

目的：探讨经皮旋转扩张气管切开术在神经科危重症患者抢救中的临床应用经验。方法：回顾分析537例行经皮旋转扩张气管切开术的神经科危重患者的手术时间、术中出血量、术后并发症及伤口愈合等情况。结果：在537例患者中有483例（89．9％）患者在10min内成功完成经皮旋转扩张气管切开术,术后出现伤口出血11例,皮下气肿7例,伤口均愈合良好。结论：经皮旋转扩张气管切开术在神经科危重患者具有良好的应用效果,具有操作简单、创伤小、伤口易于愈合、临床并发症少等特点。     

Tracheostomy in the acute setting: Patient experience and information needs

Purpose

The placement of a tracheostomy tube is a common hospital procedure used to clear secretions or bypass upper airway obstruction. However, little is known about patients' experiences of tracheostomy or the adequacy of the information provided to them.

Methods

This pilot qualitative study used semistructured interviews with 8 patients to gain a deeper understanding of their experiences. They were recruited from and interviewed in a large teaching hospital in the South of England.

Results

Four main themes were identified: physical sensations, understanding, information, and experiences after removal of the tracheostomy tube.

Conclusions

This research suggests that the experience of tracheostomy is a complex mix of physical sensations and emotions. Despite being a relatively routine procedure for clinicians, it can be very distressing to patients both during and after removal. Information needs to be more comprehensive, and it should be tailored to suit individual patient needs.     

药物气管垫在烧伤患者气管切开护理中的应用

目的 改变应用传统气管垫加重气管切开周围创面感染的局面，探索适用于烧伤患者气管切开护理需要的气管垫，以防止套管周围创面感染，减少呼吸道并发症的发生。方法 普通气管垫分别用庆大霉素、丁胺卡那霉素、磺胺嘧啶银混悬剂、碘伏浸泡后制作成药物气管垫，应用于烧伤患者气管切开护理，分别间隔4、8、12h，更换气管垫，更换时于气管切开口周围取样培养，所得数据行χ^2检验。结果 庆大霉素组间隔4、8、12h取样各26例次，细菌培养全部为阳性；丁胺卡那霉素组间隔各时间段分别取样30例次，阳性率80％～90％，各时间段之间无显著差异；磺胺嘧啶银组各时间段的细菌培养阳性率70％～80％，各间隔时间比较差异不显著；碘伏组4、8、12h各时间段的阳性率分别为6．25％、18．75％、50％，4、8、12h结果比较阳性率差异显著，而4、8h结果比较阳性率差异不显著。结论 烧伤患者气管切开护理中，应首选碘伏气管垫。     

长期气管切开老年患者的医院感染分析及护理

目的 控制气管切开老年住院患者医院感染的发生。方法 对11例长期气管切开老年患者的医院下呼吸道感染状况进行回顾性研究和分析。结果 老年患者机体抵抗力低下,平均住院时间长,下呼吸道感染发病率高,痰培养以G^-杆菌为主,铜绿假单胞菌居首。结论 气管切开是住院老年患者下呼吸道感染的主要原因之一。必须定时细菌监测,根据临床观察及监测结果及时调整治疗与用药,同时做好老年患者的心理护理,严格无菌技术管理,合理使用抗生素,保证营养。病情稳定要及时脱机,进行呼吸道训练。     

Barriers to Discharge Patients With a Tracheostomy: A Qualitative Analysis

The authors aimed to identify health care providers’ and staff’s perceived barriers to effective discharge planning for tracheostomy patients in a Veterans Administration hospital and suggest solutions for overcoming these barriers. The study involved a qualitative approach using a free listing technique to elicit responses to a single open-ended survey question. Salience analysis was performed, and 3 broad themes from participants (N = 50) were identified as barriers. Participants discussed challenges related to care coordination (S = 0.256), communication (S = 0.247), and patient and family education (S = 0.183). Results from the study can serve as a conceptual framework allowing practitioners to develop solutions to improve the discharge process.     

Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy

Objective: Tracheostomy is one of the most commonly performed surgical procedures in the critical care setting. The early use of tracheostomy as a method of primary airway management has been proposed as a means to decrease pulmonary morbidity and to shorten the number of ventilator, intensive care unit, and hospital days. We set out to (1) determine whether hypercarbia occurs during tracheostomy of the critically ill patient and (2) determine the extent to which the partial pressure of carbon dioxide in arterial blood (PaCO₂) rises during percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Design: Prospective, open clinical trial. Setting: Surgical intensive care unit and operating room in teaching hospitals. Patients: During mechanical ventilation, patients underwent either percutaneous endoscopic (PET), percutaneous Doppler (PDT), or standard surgical tracheostomy (ST), based on surgeon preference. Arterial blood gas readings were obtained approximately every 4 min throughout each procedure. Measurements and results: All tracheostomies were successfully performed. No serious complications (including hypoxia) occurred during the study. Significant (p < 0.05 vs PDT and ST) hypercarbia (maximum Δ PaCO₂ 24 ± 3 mmHg) and acidosis (maximum Δ pH – 0.16 ± 0.02) developed during PET. The changes in PaCO₂ and pH during PDT (maximum Δ PaCO₂ 8 ± 2 mmHg; maximum Δ pH – 0.07 ± 0.02) and ST (maximum Δ PaCO₂ 3 ± 1 mmHg; maximum ΔpH – 0.04 ± 0.01) were markedly less pronounced. Conclusions: Continuous bronchoscopy during percutaneous tracheostomy contributes significantly to early hypoventilation, hypercarbia, and respiratory acidosis during the procedure. Percutaneous tracheostomy, when performed using the Doppler ultrasound method to position the endotracheal tube, significantly reduces CO₂ retention when compared to PET. Because of a possible rise in intracranial pressure, the potential for hypercarbia should be considered when choosing the method of tracheostomy in the critically ill and/or head-injured patient, where hypercarbia may be detrimental. If PET is to be performed, steps to minimize occult hypercarbia, such as using the smallest bronchoscope available, minimizing suctioning during bronchoscopy, and minimizing the length of time the bronchoscope is in the endotracheal tube, should be undertaken. Received: 7 October 1996 Accepted: 6 March 1997     

External Control of Exhalation for Cough Assistance: A Method for Patients With Glottis Dysfunction and/or Tracheostomy

Lee SC, Park JH, Kang S-W, Kim DH, Song SH. External control of exhalation for cough assistance: a method for patients with glottis dysfunction and/or tracheostomy.

Objective

To investigate the effectiveness of our method of assisting a cough by mimicking the functions of the glottis in patients with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube.

Design

Before-after trial.

Setting

University rehabilitation hospital.

Participants

Patients (N=35) with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube.

Interventions

Not applicable.

Main Outcome Measures

The unassisted peak cough flow (PCF), the assisted PCF, and the assisted PCF with the external control method mimicking glottis function by an end-inspiratory external closure of the airways.

Results

Of the 35 patients, 13 were tracheostomized cervical cord injury patients, 11 were neuromuscular disease (NMD) patients with glottis dysfunction only, and 11 were NMD patients with a tracheostomy and glottis dysfunction. Assisted PCF with the external control method were higher than unassisted PCF and/or assisted PCF in all patients. Assisted PCF with the external control methods were measured in all of the patients even when the unassisted PCFs and/or assisted PCFs could not be measured. For patients with measurable assisted PCFs, the assisted PCF with the external control methods were significantly higher than the assisted PCFs.

Conclusions

We showed the effectiveness of our method of assisting a cough by external control of the glottis in patients with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube who cannot effectively cough with the help of existing cough assistance methods.     

Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: A systematic review and meta-analysis

Purpose

Multidisciplinary tracheostomy teams have been implemented in acute hospitals over the past 10 years. This systematic review of the literature and meta-analysis aimed to assess the effect of tracheostomy teams on patient outcomes.

Materials and Methods

We conducted an electronic search of the literature in the following databases: MEDLINE, CINAHL, EMBASE, and AMED. Inclusion/exclusion criteria were applied, and included articles were assessed against quality criteria. Qualitative synthesis and meta-analysis were completed.

Results

Seven studies were included. The studies were all pre-post cohort designs of low-moderate quality. Meta-analysis showed that tracheostomy teams were associated with reductions in total tracheostomy time (4 studies; mean difference, 8 days; 95% confidence interval, 6-11; P < .01; I² = 0%) and hospital length of stay (LOS) (3 studies; mean difference, − 14 days; 95% confidence interval, − 39 to 9; P = .23; I² = 50%). Reductions in intensive care unit LOS (3 studies) and increases in speaking valve (3 studies) use were also reported with tracheostomy teams.

Conclusion

There is low-quality evidence that multidisciplinary tracheostomy care contributes to a reduction in total tracheostomy time and increase speaking valve use for patients leading to improved quality of life. There is insufficient evidence to determine that multidisciplinary tracheostomy teams reduce hospital or intensive care unit LOS.     

老年患者气管切开术后并发症的原因分析与护理

目的探讨老年患者气管切开术后并发症的危险因素和护理对策。方法回顾性分析1996—2006年10月60例65～95岁行气管切开术的老年患者的病例资料,采用Logistic回归方法对可能导致并发症的13个临床因素进行分析,并提出了针对性的护理措施。结果本组患者发生术后并发症30例(50.0%),常见的并发症为伤口感染20例(33.3%)、出血10例(16.7%)、皮下气肿8例(13.3%),少见并发症为套管堵塞2例(3.3%)、气管软化2例(3.3%)、气管食管瘘2例(3.3%)、脱管1例(1.7%)。结论并发症相关危险因素有多器官功能衰竭、凝血障碍、高龄、糖尿病和置管时间过长等。根据其相关危险因素采取针对性的治疗、护理措施,可减少老年患者气管切开手术后的并发症。     

气管切开患儿照顾者居家照护体验的质性研究

目的探讨长期气管切开患儿照顾者的居家照护体验。方法采用半结构式访谈法,访谈13名照顾者,并依据Miles和Hurberman提出的质性研究资料分析法予以分析。结果经不断分析比对,共析出长期气管切开照顾者"照护负荷"、"精神困扰"及"益处发现"3个主题;"从束手无策到熟练掌握"、"亲职角色改变"、"社交隔离"等8个亚主题。结论临床工作者通过了解长期气管切开照顾者的照护体验,了解其身心反应、照护需求等。可在长期气管切开患儿入院时即构建个性化的延续护理方案,合理安排其出院后日常生活;培训照顾者各项专业操作,训练其心理调适技巧,而且可通过挖掘其自身资源促进照顾者体验积极心理变化等,以实现良好心理适应;促进患儿康复,提高其生活质量。